NCM 120:

Decent Work Employment & Transcultural

Nursing

Chapter 6

Transcultural Perspectives in the

Nursing Care of Children

Chapter 6
Transcultural Perspectives in the Nursing Care of Children
Introduction

Cultural survival depends on the transmission of values and customs from one generation to the
next; this process relies on the presence of children for success. This interdependent nature of
children and society reinforces the need for the greater society to nurture, care for, and socialize
members of the next generation. In this chapter, the composition of children as a population, the
effect of childrearing practices both specific and universal across cultures, and the cultural
influences on child growth, development, health, and illness are be examined as well as an
understanding of how transcultural concepts and evidence-based practices support the delivery of
culturally competent care for children and adolescents.

Specific Objectives

At the end of the lesson, the students should be able to:

1. Explore childrearing practices, both specific and universal across cultures, and their impact
on the development of children.
2. Analyze the impact of selected cultural beliefs and practices on the development of
children.
3. Examine the biocultural aspects of selected acute and chronic conditions affecting children.

Duration

Chapter 6: Transcultural Perspectives in the Nursing 5 hour lecture, 1 hour

Care of Children assessment

Lesson Proper

Children as a Population

When defining children as a population, it is important to consider various elements that

shape this population as a whole, such as its racial and ethnic makeup, the impact of poverty on
this population, and the health status of children and adolescents in the United States and Canada.
Other important considerations when examining this population are cross-cultural differences in
growth and development, infant attachment, and crying.
Children’s Health Status

Indicators of child health status include birth weight, infant mortality, and immunization
rates. In general, children from diverse cultural backgrounds have less favorable indicators of
health status than their white counterparts. Health status is influenced by many factors, including
access to health services. There are numerous barriers to quality health care services for children,
such as poverty, geography, lack of cultural competence by health care providers, racism, and
other forms of prejudice. Families from diverse cultures might have trouble in their interactions
with nurses and other health care providers, and these difficulties might have an adverse impact
on the delivery of health care. Because ethnic minorities are underrepresented among health care
professionals, parents and children often have different cultural backgrounds from their health care
providers.

Growth and Development

Although the growth and development of children are similar in all cultures, important
racial, ethnic, and gender differences can be identified. For example, there is cross-cultural
similarity in the sequence, timing, and achievement of developmental milestones such as smiling,
separation anxiety, and language acquisition. However, from the moment of conception, the
developmental processes of the human life cycle take place in the context of culture. Throughout
life, culture exerts an all-pervasive influence on the developing infant, child, and adolescent.

Although it is difficult to separate nongenetic from genetic influences, some populations

are shorter or taller than others are during various periods of growth and in adulthood. African
American infants are approximately three-fourths of an inch shorter at birth than Whites. In
general, African American and White children are tallest, followed by Native Americans; Asian
children are the shortest. Children of higher socioeconomic status are taller in all cultures.

The growth spurt of adolescence involves the skeletal and muscular systems, leading to
significant changes in size and strength in both sexes but particularly in boys. White North
American youths age 12 to 18 years are 22 to 33 pounds heavier and 6 inches taller than Filipino
youths the same age. African American teenagers are somewhat taller and heavier than White
teens up to age 15 years old. Japanese adolescents born in the United States or Canada are larger
and taller than Japanese adolescents who are born and raised in Japan, primarily due to differences
in diet, climate, and social milieu.

To provide consistent comparisons of height and weight of children, the WHO (2010) has
developed universally approved benchmarks for age-appropriate height/weight measures for
children up to age 5 years based on data from 11 million children in 55 different countries or
ethnic groups. Based on the wide variation in head circumference data gathered in the study, no
global standards were recommended in an effort to avoid misdiagnosis of microcephaly or
macrocephaly (Natale & Rajagopalan, 2014).

Infant Attachment
Cross-cultural differences are apparent when examining infant attachment, the relationship that
exists between a child and their primary caregiver, which provides “a secure base from which to
explore and, when necessary, as a haven of safety and a source of comfort” (Benoit, 2004).

• Researchers have discovered that German and Anglo-American mothers expect early
autonomy in the child and have fewer physical interventions as the child plays, thus
encouraging exploration and independence (Dewar, 2014).

• Japanese children are seldom separated from their mother, and there is close physical
interaction with the child (Dewar, 2014).

• Similarly, Puerto Rican and Dominican mothers display close mother–child relationships
with more verbal and physical expression of affection than European American parents.

• Anglo-American mothers tend to give greater emphasis to qualities associated with

individualism such as autonomy, self-control, and activity (Dewar, 2014). Puerto Rican
mothers describe children in terms congruent with Puerto Rican culture: emphasis is
placed on relatedness (e.g., affection, dignity, respectfulness, responsiveness to mother)
and proximity seeking (Dewar, 2014).

• The development of African children is strongly related to the nutritional status of the
child: those who tend to be malnourished have lessened attachment (Dewar, 2014).

Culture-Universal and Culture-Specific Child Rearing

The values, attitudes, beliefs, and practices of one’s culture affect the way parents and
other providers of care relate to a child during various developmental stages. In all cultures, infants
and children are valued and nurtured because they represent the promise of future generations.

A. Nutrition: Feeding and Eating Behaviors

In many cultures, breast-feeding is traditionally practiced for varying lengths of time

ranging from several weeks to several years. The growing availability and convenience of
extensively marketed prepared formula have resulted in a decrease in the number of women who
attempt to breast-feed, especially among recent migrants to the United States who may culturally
find it inappropriate to breast-feed in public. Many nursing mothers immigrating to the United
States or Canada may be separated from female family members who could assist them with
successful breast-feeding, and lack of an interpreter during prenatal and post-natal visits with
health professionals can become a barrier to breast-feeding (Schmied et al., 2012).

Some cultural feeding practices might result in threats to the infant’s health. The practice
of propping a bottle filled with milk, juice, or carbonated beverages to quiet a child or lull them
to sleep is known in many cultures and can result in dental caries; this practice should be
discouraged. In some cultures, mothers premasticate, or chew, food for young children in the
belief that this will facilitate digestion. This practice, most frequently reported among Black and
Hispanic mothers, is of questionable benefit and may transmit infection from the mother’s mouth
to the baby (Centers for Disease Control and Prevention, 2014).

Health status is dependent in part on nutritional intake, thus integrally linking the child’s
nutritional status and wellness. Although the United States is the world’s greatest food-producing
nation, nutritional status has not been a priority for many people in this country. An estimated 1%
of children in the United States are malnourished (John Hopkins Children's Center, 2015).
Malnutrition is described as undernutrition (not enough essential nutrients or nutrients excreted
too rapidly) or overnutrition (eating too much of the wrong food or not excreting enough food)
(WHO, 2010). Malnutrition may be serious enough to interfere with neuro- and musculoskeletal
development.

Malnutrition is not exclusive to children from poor, lower socioeconomic groups. By

definition, many middle- and upper-income families have obese children who are also
malnourished. Obesity frequently begins during infancy, when some mothers succumb to cultural
pressures to overfeed (Moreno, Johnson-Shelton, & Boles, 2013). For example, among many who
identify themselves as Filipino, Vietnamese, Somali, Hispanic American, and Mexican, to name
a few cultures, fat babies generally are considered healthy babies (Bresnahan, Zhuang, & Park,
2014). Among some African tribes, such as the Igbo and Yoruba in Nigeria, overweight babies
are considered healthy, and mild to moderate obesity in children is considered a sign of affluence.
Similar beliefs have been identified among Somali and Berber women (Liamputtong, 2011) as
well as some Hispanic mothers who subscribe to a long-standing cultural belief that “a chubby
baby is a healthy baby”.

The popularity of fast-food restaurants and “junk” foods has resulted in a high-calorie,
high-fat, high-cholesterol, and high-carbohydrate diet for many children. Parents and children are
frequently involved in numerous activities outside the house and have less time for traditional
tasks such as cooking or seating the family together for a meal. Because fast foods have some
intrinsic nutritional value, their benefit should be evaluated based on age-specific requirements.
Poverty forces some parents to provide inexpensive substitutes for the expensive, often
unavailable, essential nutrients. These lower nutrients, high-fat, high-calorie foods are referred to
as “empty calories” and have led to the epidemic of childhood obesity.

In many cultures, illness is viewed as a punishment for an evil act, and fasting (abstaining
from solid food and sometimes liquids) is viewed as penance for evil. A situation may become
dangerous, and even deadly, should a parent view the child’s illness as an “evil” event and
consequently withhold food and/or water. Dehydration occurs rapidly and malnutrition may
quickly follow. These dangerous issues may require legal intervention to protect the child and
may produce difficult, culturally insensitive outcomes. Nurses must be vigilant to support cultural
eating habits and be prepared to educate parents and children about the prevention of and
intervention for malnutrition and dehydration.

B. Sleep

Although the amount of sleep required at various ages is similar across cultures,
differences in sleep patterns and bedtime rituals exist. The sleep practices in a family household
reflect some of the deepest moral ideals of a cultural community. Nurses working with families
of young children in both community and inpatient settings frequently encounter cultural
differences in family sleeping behaviors. Community health, psychiatric, and pediatric nurses who
work with young children and their families often assess the family’s sleep and rest patterns. Bed-
sharing is the practice of a child sleeping with another person on the same sleeping surface for
all or part of the night. Although bed-sharing may be born out of financial necessity, it is a cultural
phenomenon in many societies emphasizing closeness, togetherness, and interdependence.

C. Elimination

Elimination refers to ridding the body of waste. It is a function accomplished by the

combined work of the body's gastrointestinal, genitourinary, respiratory, and integumentary
systems. Of primary concern to parents of toddlers and preschoolers is bowel and bladder control.
Toileting or toilet training is a major developmental milestone and is taught through a variety of
cultural patterns.

Most children can achieve dryness by 2½ to 3 years of age. Bowel training is more easily
accomplished than bladder training. Daytime (diurnal) dryness is more easily attained than
nighttime (nocturnal) dryness. Some cultures start toilet training a child before his or her first
birthday and consider the child a “failure” if dryness is not achieved by 18 months. Often, there
is significant shaming, blaming, and embarrassment of the child who has not achieved dryness by
the culturally acceptable timetable.

Constipation in a child is a persistent concern among parents who expect a ritualistic daily
pattern of bowel movements. In some cultures, infants are given herbs aimed at purging them
when they are a few days, weeks, or months old to remove evil spirits from the body. Parents
should be advised against using purgatives in infants because fluid and electrolyte imbalance
occurs, and dehydration can ensue rapidly.

The nurse's role is to acknowledge that toilet training can be taught through various
cultural patterns. Still, physical and psychosocial health is promoted by accepting, flexible
approaches. A previously toilet-trained child might become incontinent due to the stress of
hospitalization but will generally regain control quickly when returned to the familiar home
environment. Parents should be reassured that bowel and bladder control regression frequently
occurs when a child is hospitalized; this is normal and is expected to be a short-term occurrence.
D. Menstruation

Ethnicity is the strongest determinant of the duration and character of menstrual flow,
although diet, exercise, and stress are also known to influence menstruation in women of all ages.
In most cultures globally, menarche signals that a girl’s body is physiologically becoming ready
for motherhood.

Attitudes toward menstruation are often culturally based, and the adolescent girl might be
taught many folk beliefs. For example, in traditional Mexican American families, girls and women
are not permitted to walk barefooted, wash their hair, or take showers or baths during menses. In
encouraging hygienic practices, respect cultural directives by encouraging sponge bathing,
frequent changing of sanitary pads or tampons, and other interventions that promote cleanliness
(Davis et al., 2011). Some Mexican Americans believe that sour or iced foods cause the menstrual
flow to thicken, and some Puerto Rican teenagers have been taught that drinking lemon or
pineapple juice will increase menstrual cramping. The nurse should be aware of these beliefs and
should respect personal preferences concerning beverages. The teenager might have been taught
the folk practices by her mother or by another woman in her family who might be watchful during
the girl’s menstrual periods. If menstruation coincides with hospitalization, nurses should respect
the teenager’s preferences and reassure the mother or significant other that cultural practices will
be respected.

Many cultural groups treat menstrual cramping with herbs and a variety of home remedies.
Health care providers should ask the adolescent whether she takes anything special during
menstruation or in the absence of menstrual flow. Verify the amount and type of home remedies
used to determine possible interactive effect with prescribed medications.

Adolescent girls of Islamic religious backgrounds have cultural and/or religious

prohibitions and duties during and after menstruation. In Islamic law, blood is considered unclean.
The blood of menstruation, as well as blood lost during childbirth, is believed to render the female
impure. Because one must be in a pure state to pray, menstruating girls and women are forbidden
to perform certain acts of worship, such as touching the Koran, entering a mosque, praying, and
participating in the feast of Ramadan. During the menstrual period, sexual intercourse is forbidden
for both men and women. When the menstrual flow stops, the girl or woman performs a special
washing to purify herself. In Islam, sexual pollution applies equally to men and women. For men,
sexual intercourse and the discharge of semen is an act that renders a man impure and requires a
ritual washing before being able to perform the prayer. Buddhist and Hindu women do not enter
the kitchen and may sleep in separate/special rooms during menses (Davis et al., 2011).

E. Parent-Child Relationships and Discipline

In some cultures, both parents assume responsibility for the care of children, whereas in
other cultures, the relationship with the mother is primary and the father remains somewhat
distant. With the approach of adolescence, the gender-related aspects of the parent–child
relationship might be modified to conform to cultural expectations.

Some cultures encourage children to participate in family decision making and to discuss
or even argue points with their parents. Some African American families, for example, encourage
children to express opinions verbally and to take an active role in all family activities. Many Asian
parents value respectful, deferential behavior toward adults, who are considered experienced and
wise; therefore, children are discouraged from making decisions independently. The witty, fast
reply that is viewed in some US, Canadian, European, and Australian cultures as a sign of
intelligence and cleverness might be punished in some non-Western circles as a sign of rudeness
and disrespect.

The use of physical acts, such as spanking or various restraining actions, is connected with
discipline in many groups, but can sometimes be interpreted by those outside the culture as
inappropriate and/or unacceptable. Physical punishment of Native North American children is
rare. Instead of using loud scolding and reprimands, Native North American parents generally
discipline with a quiet voice, telling the child what is expected. During breast-feeding and toilet
training, or toilet learning, Native North American children are typically permitted to set their
own pace, and parents tend to be permissive and nondemanding. Some African American parents
tend to point out negative behaviors of a child and may use spanking and physical punishment as
a strategy to quickly gain the child’s attention and rapidly get him or her to behave, especially in
public (Whaley, 2013).

F. Health Belief Systems and Children

Among many cultural groups, traditional health beliefs coexist with Western medical
beliefs. Members of a cultural group choose the components of traditional (Western) medicine,
Eastern medicine, or folk beliefs that seem appropriate to them. A Mexican American family, for
example, might take a child to a physician and/or a traditional healer (curandero). After visiting
the physician and the curandero, the mother might consult with her own mother and then give
her sick child the antibiotics prescribed by the physician and the herbal tea prescribed by the
traditional healer. If the problem is viral in origin, the child will recover because of his or her own
innate immunologic defenses, independent of either treatment. Thus, both the herbal tea of the
curandero and the penicillin prescribed by the physician might be viewed as folk remedies; neither
intervention is responsible for the child’s recovery.
Belief systems about specific symptoms are culturally unique. These are referred to as
cultural illnesses. In Hispanic culture, susto is caused by a frightening experience and is
recognized by nervousness, loss of appetite, and loss of sleep. Mexican American babies must be
protected from these experiences. Pujos (grunting) is an illness manifested by grunting sounds
and protrusion of the umbilicus. It is believed to be caused by contact with a woman who is
menstruating or by the infant’s own mother if she menstruated sooner than 60 days after delivery.
The evil eye, mal ojo, is an affliction feared throughout much of the world. The condition is said
to be caused by an individual who voluntarily or involuntarily injures a child by looking at or
admiring him or her. The individual has a desire to hold the child, but the wish is frustrated, either
by the parent of the infant or by the reserve of the individual. Several hours later, the child might
become listless, cry, experience fever, vomiting, and/or diarrhea. The most serious threat to the
infant with mal ojo is dehydration; the nurse encountering this problem in the community setting
needs to assess the severity of the dehydration and plan for immediate fluid and electrolyte
replacement. Parents should be taught the warning signs and the potential seriousness of
dehydration. A simple explanation of the causes and treatment of dehydration should be provided.
If the parents adhere strongly to traditional beliefs, respect their desire for the curandera to
participate in the care. Parents or grandparents might wish to place an amulet, talisman, or
religious object such as a crucifix or rosary on the child or near the bed.
For the Mexican American family, caida de la mollera, or fallen fontanel, can be attributed
to a number of causes such as failure of the midwife to press preventively on the palate after
delivery, falling on the head, abruptly removing the nipple from the infant’s mouth, and failing to
place a cap on the infant’s head. The signs of this condition include crying, fever, vomiting, and
diarrhea. Given that health care providers frequently note the correspondence of these symptoms
with those of dehydration, many parents see deshidratacion (dehydration) or carencia de agua
(lack of water) as synonymous with caida de la mollera. Although regional differences exist,
parental treatment usually is directed at rehydration, thus raising the fontanel. Empacho is a
digestive condition believed by Mexicans to be caused by the adherence of undigested food to
some part of the gastrointestinal tract. This condition causes an “internal fever,” which cannot be
observed but which betrays its presence by excessive thirst and abdominal swelling believed to
be caused by drinking water to quench the thirst. Children who are prone to swallowing chewing
gum are believed to experience empacho, but it can affect persons of any age.
Among some Hindus from northern India, there is a strong belief in ghost illness and ghost
possession. These culture-bound syndromes, or folk illnesses, are based on the belief that a ghost
enters its victim and tries to seize the soul. If the ghost is successful, it causes death. Illness and
the supernatural world are linked by the concepts of fever and the ghost, which is a supernatural
being discussed in Hindu sacred scriptures. One sign of ghost illness is a voice speaking through
a delirious victim; this may occur in children and adults. Other signs are convulsions and body
movements, indicating pain and discomfort, and choking or difficulty breathing. In the case of an
infant, incessant crying is a sign. The psychological state of the parents is often involved in the
diagnosis, and some believe that ghosts might be cultural scapegoats for the illness and death of
children. When an infant or small child becomes ill and dies, a mother or father might be relieved
of psychic tension from feelings of personal guilt by transferring the blame for the death to a
ghost.

G. Beliefs Regarding the Cause of Chronic Illnesses and Disabilities

Inherited disorders and illnesses are frequently envisioned as being caused by a family
curse that is passed along from one generation to the next through blood. Within such families,
the nurse’s desire to determine who is the carrier for a particular gene might be interpreted as an
attempt to discover who is at fault and might be met with family resistance.
Folk beliefs mingled with eugenics have resulted in the realization that many chronic
conditions, particularly intellectual disability, are the products of intermarriage among close
relatives (Agency for Healthcare Research and Quality, 2014). The belief that a chronically ill or
disabled child might be the product of an incestuous relationship can further complicate attempts
to encourage parents to seek assistance.
Among those who believe that chronic illness and disability are caused by an imbalance
of hot and cold (as in Latino cultures) or yin and yang (as in Southeast Asian cultures), the cause
and potential cure lie within the individual. He or she must try to reestablish equilibrium through
regaining balance. Unfortunately for those with permanent disabilities who cannot be fully healed,
their community might perceive them as living in a continually impure or diseased state.
Traditional beliefs can be tenacious and tend to remain even after genetic inheritance or
physiologic patterns of chronic disease progression are explained to the family. However, new
information is quickly integrated into the traditional system of folk beliefs more often, as is
evidenced by the addition of currently prescribed medications to the hot/cold classification system
embraced by many Hispanic families. An explanation of the genetic transmission of disease might
be given to a family, but this does not guarantee that the older, traditional belief in a curse or “bad
blood” will disappear.
When disability is seen as a divine punishment, an inherited evil, or the result of a personal
state of impurity, the very presence of a child with a disability might be something about which
the family is deeply ashamed or with which they are unable to cope. In addition to suffering from
public disgrace, some parents or families, especially immigrant groups from Eastern Europe and
Southeast Asia, also fear that disabled children will be taken away and institutionalized against
their will.
Some cultural explanations of the cause of chronic disease or disability are quite positive.
For example, some Mexican American parents of chronically ill children believed that a certain
number of ill and disabled children would always be born into the world. Many Mexican
American parents who embrace Roman Catholicism believe that God has singled them out for the
role because of their past kindnesses to a relative or neighbor who was disabled and view the birth
of the disabled infant as God’s will.
References

Agency for Healthcare Research and Quality. (2014). 2013 National Healthcare Disparities
Report. U.S. Department of Health and Human Services (AHRQ Publication No. 14–0006.
Rockville, MD: Author).

Benoit, D. (2004). Infant-parent attachment: Definition, types, antecedents, measurement and

outcome. Paediatrics & Child Health, 9(8), 541–545.

Bresnahan, M., Zhuang, J., & Park, S. (2014). Cultural differences in the perception of health and
cuteness of fat babies. The International Journal of Communication and Health (4), 52–58.

Centers for Disease Control and Prevention. (2014). Infant Feeding Practices Study II and its year
six follow-up. Retrieved from Centers for Disease Control and Prevention:
http://www.cdc.gov/ifps/index.htm

Davis, A., Farage, M. A., & Miller, K. W. (2011). Cultural aspects of menstruation and menstrual
hygiene in adolescents. Expert Review of Obstetrics & Gynecology, 6, 127–13. Retrieved
from http://libproxy.umflint.edu:2166/
ps/i.do?id=GALE%7CA252101667&v=2.1&u=lom_umic
hflint&it=r&p=HRCA&sw=w&asid=911f2622653592b7a c0bf2bde25ef26e

Dewar, G. (2014). The science of attachment parenting. Retrieved from Parenting Science:
http://www.parentingscience.com/attachment-parenting.html

John Hopkins Children's Center. (2015). Malnutrition. Retrieved October 11, 2023 from
http://www.hopkinschildrens.org/Malnutrition.aspx

Liamputtong, P. (2011). Infant feeding practices: A cross-cultural perspective. New York, NY:
Springer Science + Business Media.

Moreno, G., Johnson-Shelton, D., & Boles, S. (2013). Prevalence and prediction of overweight
and obesity among elementary school children. Journal of School Health, 83(1), 157–163.

Schmied, V., Olley, H., Burns, E., Duff, M., Dennis, C., & Dahlen, H. G. (2012). Contradictions
and conflict: A meta-ethnographic study of migrant women’s experience with breastfeeding
in a new country. Biomedical Central Pregnancy and Childbirth, 12, 163–174.

Whaley, A. (2013). Sociocultural differences in the developmental consequences of using physical

discipline during childhood. Cultural Diversity and Ethnic Minority Psychology, 6(1), 5–12.

World Health Organization. (2010). Enhancing the rights of adolescent girls. Geneva, Switzerland:
WHO.